Upper Cross System Head Injuries & Neck Injuries

1. Upper Cross SystemHead Injuries& Neck Injuries

2. Upper Cross System • When a chain reaction evolved muscle shortening and reciprocal weakening in predictable patterns causing predictable imbalances or “syndromes”:

3. Upper Cross System Imbalances

4. Changes due to Lower Cross System • Occiput and C1/2 hyperextend with the head pushed forward • Lower cervical to 4th thoracic vertebrae are stressed through posture • Rotation and abduction of the scapulae • Altered direction of the glenoid fossa • Results in the need for humeral stability (increases levator and upper trap activity & supraspinatus)

5. Cervical Spine Forces • A) Absolute rotation angle (ARA) of overall lordosis magnitude. B) Relative rotation angle (RRA) or magnitude of intersegmental angle. C) Linear measure of forward displacement of head relative to upper dorsal spine

6. Results of Postural Imbalance • Greater cervical segment strain with possible referred pain to the chest (“trigger points”) • Pain mimicking angina may be noted • Rotator Cuff strain/tendonitis • TMJ • Lower Cross System may occur due to eye gaze • In order to see straight ahead, individual must anteriorly tilt pelvis • Breathing dysfunction – reduce in diaphragmatic efficiency due to postural restriction of lower rib cage

7. Head Evaluation and Treatment

8. Boney Anatomy • The Skull has many specialized areas. We sill focus on Major areas • Frontal • Parietal • Temporal • Occipital

9. Special Boney Areas • External Occipial Protuberance (notch in occipital area • Mastoid Process (behind Ear) • Zygomatic Arch (Cheekbone) • Orbit (eye socket) • Maxilla (upper jaw) • Mandible (lower Jaw)

10. Anatomical Locations of Cranial Nerves

11. Meninges Bone/Skull Dura Mater Pia Mater Arachnoid Mater Cerebral Cortex

12. Protection of Brain and Spinal Cord • Protection is through the bony anatomy and the MENINGES • Dura Mater A very tough and thick covering (highly vascular between dura mater and bone (aterires here) • Arachnoid: The subarachnoid space exists between arachnoid and pia mater and is C.S.F. and passage for veins in the cranial cavity(veins in this area) • Pia Mater: a thin and “invisible” covering attached intimately to the neural structures

13. Head Injury Background • Skull - Hard casing with pudding like substance inside • Protected by coverings • Nutrients by rich blood supply • Neural Components at base of skull

14. Head Injury • Mechanism • Coupe • Contra-Coupe • These mechanisms can cause injury and swelling: • Concussion • Epidural/subdural Hematoma

15. Bleeding in the Brain

16. Check Visual Acuity & eye movement Facial movement Headache ringing in the ears Nausea Behavioral Changes (unlike normal personality) Amnesia (retrograde/ post-concussive) MUST SIT OUT 20 MINUTES AND REASSESS If symptoms increase send to emergency This is a limited list Assessing Head Injury

17. First Degree No Concussion - Bell rung resolution of symptoms within Lucid Interval Second Degree Loss of Consciousness brief less than 15 seconds. No resolution within lucid interval Third Degree Loss of Consciousness more than 15 seconds increasing severity within lucid interval This is only one type of scale many variations Head Injury

18. Post-Concussive Syndrome • Residual symptoms post concussion including • Nausea • Headache • Tinnitus • etc. • These may occur with movement, daily activities, rising from bed etc. • Must not participate during this period of time

19. Second Impact Syndrome • Injury while still recovering from initial concussion • 100% morbidity • Very important that post-concussive syndrome has resolved

20. Decisions on Head Injuries • MUST SEND TO EMERGENCY IF: • Blood out of ears &/or nose (from blow to head) • Any unconscious episode • Symptoms increase during 20 minute waiting period or when activity resumes • DO NOT RETURN TO ACTIVITY IF: • Symptoms are not resolved • Activity exacerbates headache

21. CSF is main nutrition to the neural structures. Blood supply to the brain is via a paired arteriole system Two internal carotid arteries enter the brain through the neck Two vertebral arteries travel up the posterior aspect of the neck through the transverse foramen and at the level of the pons. This then becomes the basilar artery. The basilar will nourish the pons and the cerebellum along the way to the area of the midbrain where it will divide into the posterior cerebral arteries Blood Supply to the Brain

22. First Concussion 1º 1 week post resolution of Symptoms Second Concussion or 2 º 1 month post resolution of symptoms Third Concussion or 3 º End of Season needs discussion of career Start with bike activity - if no symptoms increase functional activity before full return Above subject to Dr Discretion Athlete Return to Activity

23. Circle of Willis • Two communicating links exist: • Posterior communicating artery links the posterior and middle cerebral arteries’ • The anterior communicating artery unites the two anterior cerebral arteries

24. Circle of Willis • 1. Anterior Cerebral Arteries • 2. Inter-Carotid Arteries • 3/5. Middle Cerebral • 4. Posterior Communicating Arteries • 6/7.Posterior Cerebral Arteries • 8. Basilar Arteries • 9. Vertebral Arteries

25. Where the Head Ends and Neck Begins • Plane between the external occipital protuberance and inferior surface of the mandible • Neck • Anterior triangle is bordered by Mandible (above), Cervical midline(laterally) and Sternomastoid (anteriorly

26. Where the Head Ends and Neck Begins • Neck • Posterior triangle is bordered by Clavicle (below), trapezius (posteriorly) and Sternomastoid (anteriorly)

27. Arteries Middle Cerebral Artery Posterior Cerebral Artery ICA Anterior Cerebral Artery

28. Neck Anatomy, Evaluation and Treatment

29. Typical Vertebrae are C3-C6 Characteristics Small bodies with large vertebral foramen bifed spinous process foramen in each transverse process articular facets lie at 45° in transverse plane Atypical Vertebrae Atlas - 1st cervical vertebrae Axis - 2nd Cervical Vertebrae Boney Anatomy of the Neck

30. Atlas • Has a short anterior and long posterior arch • Atlas has no actual body • Has Circular facet (Fovia Dentis) in the anterior arch which is for the articulation of the dens of C2

31. Atlas/Axis Ligaments • Anterior Atlanto-Axial and atlanto-Occipital Ligaments • Lie on the anterior surface of the axis and passes to the anterior surface of the anterior arch of the atlas and onto the the tubercle of the occiput This is an extension of the anterior longitudinal Ligament

32. Atlas/Axis Ligaments • Posterior Atlanto-Axial and atlanto-Occipital Ligaments • Extends for the lamina of the axis to the posterior arch of the atlas and on up to the occiput.

33. Atlas/Axis Ligaments • Tectorial Membrane • Extends on the posterior aspect of the body of the axis covering the dens and its associated ligaments but not touching it. It continues up to the anterior edge of the foramen magnum

34. Axis Anatomy • Second Cervical Vertebra • DENS which is fused body of the atlas and axis • helps in the formation of the first intervertebral foramen which the second cervical nerve passes through Lateral View Overhead View

35. Axis Anatomy • Cruciform Ligament • Most vital of the ligaments. IF consists of 2 ligaments (Apical & Alar) which cross. • Apical: Attaches the tip to the occiput • Alar: Also attaches to occiput • Transverse lig: over apical but does not attach to it Lateral View Odontoid Anterior View

36. Jefferson Fracture “Burst Fracture” • Etiology: • Axial Loading of the head/compression of the atlas between occiptial condyles • Pathology • Bilateral burst fracture of both the anterior and posterior arched of C-1 with lateral displacement of masses - increasing the distance between anterior arch of the atlas and odontoid process of axis (> 3mm). AN UNSTABLE INJURY WITHOUT SPINAL CORD TRAUMA

37. Avulsion “teardrop” Fracture (Axis) • Etiology: • Hyperextension • Pathology • Triangular shaped avulsion fracture of the anterior-inferior margin of the C-2 vertebral body at the insertion of the anterior longitudinal ligament

38. Teardrop Fracture (vertebral Body) • Etiology: • Axial Loading/compression and Flexion “Buckling” • Pathology • A “Burst” fracture of the vertebral body with associated rupture of the posterior ligament, posterior displacement of the posterior fracture fragment and spinal cord encroachment “acute anterior spinal cord injury syndrome” TYPE IV compression fracture

39. Fractures of Neural Arch • Etiology • Axial Loading/flexion or extension “buckling” • Pathology • Unilateral or bilateral fractures of the lamina and/or pedicles • Avulsion fracture of the spinous process usually involving C-6, C-7 (most common)

40. Unilateral Facet Subluxation/Dislocation • Etiology • Axial Loading/flexion-rotation • Pathology • Rupture of the anterior and posterior ligaments, capsular ligaments (bilateral) and intervertebral disc with anterior subluxation (less than 50% of vertebral body) or dislocation (more than 50% of vertebral body/”locked facets). An unstable injury

41. Atlantoaxial Subluxation/Dislocation • Etiology • Flexion or axial loading/flexion “buckling” • Pathology • Rupture of transverse and alar ligaments with anterior dislocation of C-1 on C-2/increase in ADI (distance between anterior arch of atlas and odontoid process of axis greater than 3mm)

42. Fracture of Posterior Arch (atlas) • Etiology • Extreme hyperextension or axial loading/compression of the atlas between the occipital condyle and the axis • Pathology • Fracture of the posterior arch , most commonly at the thin, weak junction. Possible associated fracture including pedicle of C2 (hangman’s fracture) avulsion “teardrop”fracture of the axis etc.

43. Odontoid Fractures (Axis) • Etiology • Axial Loading/Compression shearing forces • Pathology • Type I - Avulsion fracture (Alar ligament) of the tip of the odontoid unstable • Type II - Fracture at the junction of odontoid and body of axis (unstable • Type III - Fracture of the body of the axis (unstable)

44. Hangman’s Fracture • Etiology • Hyperextension or axial loading/extension “Buckling” • Pathology • A bilateral arch fracture of C-2 (traumatic spondylolysis) with anterior dislocation of C-2 and C-3 (spondylolithesis) An unstable injury

45. Face Injury - LaForte Fracture • LaForte I: • LaForte II • LaForte III